Ehlenbach William J, Gilmore-Bykovskyi Andrea, Repplinger Michael D, Westergaard Ryan P, Jacobs Elizabeth A, Kind Amy J H, Smith Maureen
Department of Medicine, Divisions of Pulmonary and Critical Care Medicine, and Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
School of Nursing, University of Wisconsin-Madison, Madison, WI.
Crit Care Med. 2018 Jan;46(1):37-44. doi: 10.1097/CCM.0000000000002755.
Severe sepsis survivors frequently experience cognitive and physical functional impairment. The degree of impairment and its association with mortality is understudied, particularly among those discharged to a skilled nursing facility. Our objective was to quantify the cognitive and physical impairment among severe sepsis survivors discharged to a skilled nursing facility and to investigate the relationship between impairment and long-term mortality.
Retrospective cohort study.
United States.
Random 5% sample of Medicare patients discharged following severe sepsis hospitalization, 2005-2009 (n = 135,370).
Medicare data were linked with the Minimum Data Set; Minimum Data Set-Cognition Scale was used to assess cognitive function, and the Minimum Data Set activities of daily living hierarchical scale was used to assess functional dependence. Associations were evaluated using multivariable logistic regression, Kaplan-Meier curves, and Cox proportional hazards regression. Of 66,540 beneficiaries admitted to a skilled nursing facility following severe sepsis, 34% had severe or very severe cognitive impairment, and 72.5% had maximal, dependence, or total dependence in activities of daily living. Median survival was 19.4 months for those discharged to a skilled nursing facility without having been in a skilled nursing facility in the preceding 1 year and 10.4 months for those discharged to a skilled nursing facility who had spent time in a skilled nursing facility in the prior year. The adjusted hazard ratio for death was 3.1 for those with very severe cognitive impairment relative to those who were cognitively intact (95% CI, 2.9-3.2; p < 0.001) and 4.3 for those with "total dependence" in activities of daily livings relative to those who were independent (95% CI, 3.8-5.0; p < 0.001).
Discharge to a skilled nursing facility following severe sepsis hospitalization among Medicare beneficiaries was associated with shorter survival, and cognitive impairment and activities of daily living dependence were each strongly associated with shortened survival. These findings can inform decision-making by patients and physicians and underscores high palliative care needs among sepsis survivors discharged to skilled nursing facility.
严重脓毒症幸存者经常出现认知和身体功能障碍。这种障碍的程度及其与死亡率的关联研究不足，尤其是在那些出院后入住专业护理机构的患者中。我们的目的是量化出院后入住专业护理机构的严重脓毒症幸存者的认知和身体障碍，并研究障碍与长期死亡率之间的关系。
回顾性队列研究。
美国。
2005年至2009年因严重脓毒症住院后出院的医疗保险患者的5%随机样本（n = 135,370）。
医疗保险数据与最低数据集相关联；使用最低数据集认知量表评估认知功能，使用最低数据集日常生活活动分级量表评估功能依赖。使用多变量逻辑回归、Kaplan-Meier曲线和Cox比例风险回归评估关联。在66,540名严重脓毒症后入住专业护理机构的受益人中，34%有严重或非常严重的认知障碍，72.5%在日常生活活动中处于最大依赖、依赖或完全依赖状态。对于那些出院后入住专业护理机构且前一年未入住过专业护理机构的患者，中位生存期为19.4个月；对于那些出院后入住专业护理机构且前一年曾入住过专业护理机构的患者，中位生存期为10.4个月。与认知功能正常者相比，认知障碍非常严重者的调整后死亡风险比为3.1（95%CI，2.9 - 3.2；p < 0.001）；与独立者相比，日常生活活动“完全依赖”者的调整后死亡风险比为4.3（95%CI，3.8 - 5.0；p < 0.001）。
医疗保险受益人严重脓毒症住院后出院入住专业护理机构与生存期缩短相关，认知障碍和日常生活活动依赖均与生存期缩短密切相关。这些发现可为患者和医生的决策提供参考，并强调出院后入住专业护理机构的脓毒症幸存者对姑息治疗的高需求。
